A Comprehensive Rehabilitation Program for Treating Lateral Elbow Tendinopathy

Scapular muscle weakness in patients with lateral elbow tendinopathy is an identified impairment and is part of a multimodal rehabilitation approach. The published literature provides little information regarding specific rehabilitation guidelines that address both the proximal scapular muscle weakness and local elbow/ wrist dysfunctions common in patients with lateral elbow tendinopathy. The purpose of this clinical commentary is to describe a comprehensive rehabilitation strategy for individuals with lateral elbow tendinopathy. This program emphasizes a phased therapeutic strategy that addresses proximal and local dysfunction along the kinetic chain. This clinical protocol is currently being tested for efficacy as part of a randomized controlled trial. The information in this commentary is intended to provide clinicians with sufficient detail to comprehensively guide the rehabilitation of a patient with lateral elbow tendinopathy. Level of Evidence:

Upper Extremity Strength Characteristics in Female Recreational Tennis Players With and Without Lateral Epicondylalgia

STUDY DESIGN: Descriptive, cross-sectional. OBJECTIVES: To compare static strength characteristics of the upper extremity musculature in female recreational tennis players with lateral epicondylalgia to those of nonsymptomatic tennis players and a control group of women who did not play tennis. BACKGROUND: There is a paucity of research describing the relationship between lateral epicondylalgia and strength characteristics of the upper extremity musculature, despite the functional relationship between the shoulder, elbow, and wrist. METHODS: Sixty-three women were recruited into 3 groups (n = 21 per group): symptomatic tennis players (SIP) with lateral epicondylalgia, nonsymptomatic tennis players, and controls. Data collection was performed during a single session, during which the strength of selected muscle groups of the dominant upper extremity was measured using a combination of force transducers. Strength ratios of selected muscle groups were then calculated. RESULTS: The SIP group reported median pain level of 3/10 on a numeric pain rating scale and a symptom duration of 16 weeks. The SIP group had weaker lower trapezius strength (mean difference, -9.0 N; 95% confidence interval [CI]: -13.5, -4.4) and wrist extensor strength (-12.7 N; 95% CI: -24.4, -1.1), and a higher shoulder internal/external rotation strength ratio (0.19; 95% CI: 0.02, 0.35) and upper/lower trapezius strength ratio (1.32; 95% CI: 0.41, 2.23), compared to those of the nonsymptomatic group. Compared to the control group, the SIP group demonstrated a significantly higher shoulder internal/external rotation strength ratio (0.21; 95% CI: 0.04, 0.38) and wrist flexion/extension strength ratio (0.14; 95% CI: 0.01, 0.27). CONCLUSION: In this group of recreational female tennis players, significant differences in strength and strength ratio characteristics were identified. Although the design of the study precludes establishing a cause-and-effect relationship, the results suggest further study and treatment of the muscle groups of interest

Characteristics of the upper extremity in female recreational tennis players with and without lateral epicondylalgia

Problem Statement: A paucity of research exists describing the relationship between lateral epicondylalgia (LE) and upper extremity (UE) strength, range of motion or joint characteristics, between the shoulder, elbow and wrist despite the close kinetic relationship. The primary purpose of this study was to describe these characteristics of the UE in female tennis players and a control group. Methods: This was a descriptive study of three groups: sample of active adult females with no elbow pain (control), non-symptomatic tennis players (NSTP), and symptomatic tennis players (STP) with LE. A convenience sample of three groups, 21 women each was recruited. A questionnaire was completed by each participant and a screening procedure was performed to confirm group assignment and gather tennis specific information. The dependent variables were collected at a one-time session for the dominant extremity of each subject and included UE passive motion, mean UE adjusted strength values, strength ratios, elbow carrying angle, posterior shoulder tightness, anterior glenohumeral joint (GHJ) laxity and shoulder impingement tests. Results: The STP group demonstrated significantly greater passive forearm pronation, higher internal/external rotation strength ratios, increased frequency of anterior GHJ hyperlaxity and positive Hawkins-Kennedy test results. Grip strength taken in elbow extension was significantly weaker in the STP group compared with the NSTP and control groups. The strength ratio of the upper/lower trapezius was significantly greater in the STP compared to NSTP group, but was not significantly different from the control group. The STP group demonstrated a trend toward greater passive motion in elbow hyperextension and supination, and a higher wrist flexion/extension ratio that did not reach statistical significance. Both tennis player groups demonstrated limited passive wrist flexion and shoulder internal rotation when compared to controls. No significant differences were found in tennis playing factors between the groups. Conclusion: Impairments in strength, range of motion, or motor control are hypothesized to contribute to the altered kinematics of the UE and may potentially lead to LE in recreational tennis players. Recognizing risk factors a priori may provide a framework to guide the physical evaluation, treatment plan and preventative techniques for the tennis player exhibiting symptoms of LE

Risk Management Strategies in Physical Therapy: Documentation to Avoid Malpractice

PURPOSE: This article aims to highlight the importance of a complete and accurate medical record as it pertains to potential risk exposure in the outpatient physical therapy profession. DESIGN/METHODOLOGY/APPROACH: Basic charting rules, correction and alteration recommendations, documentation of telephone conversations, informed consent, exculpatory release forms and incident reports are discussed. Basic risk management strategies are reviewed that may reduce outpatient physical therapy practitioners\u27 malpractice exposure. FINDINGS: The authors contend that quality and thorough documentation is as important as the quality of the care that is delivered to patients, since medical records are legal documents and serve as valuable evidence as to what transpired between patients and the healthcare providers. ORIGINALITY/VALUE: Practical documentation strategies are described in a manner that will inform physical therapists of their legal obligations relating to patient care

Response Letter to ‘The Role of Proprioception of Lateral Elbow Tendinopathy’

Stasinopoulous puts forth an important commentary regarding the need to further examine the role of proprioception in the development or perpetuation of lateral elbow tendinopathy (LET). We believe that it is also important for therapists to recognize all the conscious and unconscious mechanisms that help to control movement around the joint including both the role that the contractile units play in providing both dynamic stability and gross motor actions around the limb in general. All periarticular tissues, including ligament, tendon, and muscle, contain important mechanoreceptors to collect sensory information that is communicated to the central nervous system. Proprioceptive capabilities of periarticular tissues ensure accurate information about the joint and muscles to enable precise neuromuscular control. Therefore, deficits in proprioception could contribute to poor neuromuscular control and thus injury

Do Joint Mobilizations Assist in the Recovery of Lateral Elbow Tendinopathy? A Systematic Review and Meta-Analysis

Study Design: Systematic review. Introduction: No consensus exists as to which are the most effective methods to treat the symptoms associated with lateral elbow tendinopathy (LET). Research has suggested that joint mobilizations may assist in the recovery of patients with LET. Purpose of the Study: To determine if joint mobilizations are effective in improving pain, grip strength, and disability in adults with LET. Methods: Searches in 3 databases were performed to identify relevant clinical trials. Reviewers independently extracted data and assessed the methodological quality. Summary measures of quantitative data were extracted or calculated where possible. Appropriate data were pooled for meta-analysis using a random-effects model. Results: A total of 20 studies met the inclusion criteria; 7 were included in the meta-analysis. Studies were broadly classified into 3 groups: mobilization with movement (MWM), Mill\u27s manipulation, and regional mobilization techniques. Pooled data across all time periods demonstrated a mean effect size of 0.43 (95% confidence interval [CI]: 0.15-0.71) for MWM on improving pain rating, and 0.31 (95% CI: 0.11-0.51) for MWM on improving grip strength, 0.47 (95% CI: 0.11-0.82) for Mill\u27s manipulation on improving pain rating. A mean effect size of −0.01 (95% CI: −0.27 to −0.26) shows Mill\u27s manipulation did not improve pain free grip strength. Functional outcomes varied considerably among studies. Pain, grip strength, and functional outcomes were improved with regional mobilizations. Conclusion: There is compelling evidence that joint mobilizations have a positive effect on both pain and/or functional grip scores across all time frames compared to control groups in the management of LET

Upper extremity strength characteristics in female recreational tennis players with and without lateral epicondylalgia.

STUDY DESIGN: Descriptive, cross-sectional. OBJECTIVES: To compare static strength characteristics of the upper extremity musculature in female recreational tennis players with lateral epicondylalgia to those of nonsymptomatic tennis players and a control group of women who did not play tennis. BACKGROUND: There is a paucity of research describing the relationship between lateral epicondylalgia and strength characteristics of the upper extremity musculature, despite the functional relationship between the shoulder, elbow, and wrist. METHODS: Sixty-three women were recruited into 3 groups (n = 21 per group): symptomatic tennis players (STP) with lateral epicondylalgia, nonsymptomatic tennis players, and controls. Data collection was performed during a single session, during which the strength of selected muscle groups of the dominant upper extremity was measured using a combination of force transducers. Strength ratios of selected muscle groups were then calculated. RESULTS: The STP group reported median pain level of 3/10 on a numeric pain rating scale and a symptom duration of 16 weeks. The STP group had weaker lower trapezius strength (mean difference, -9.0 N; 95% confidence interval [CI]: -13.5, -4.4) and wrist extensor strength (-12.7 N; 95% CI: -24.4, -1.1), and a higher shoulder internal/external rotation strength ratio (0.19; 95% CI: 0.02, 0.35) and upper/lower trapezius strength ratio (1.32; 95% CI: 0.41, 2.23), compared to those of the nonsymptomatic group. Compared to the control group, the STP group demonstrated a significantly higher shoulder internal/external rotation strength ratio (0.21; 95% CI: 0.04, 0.38) and wrist flexion/extension strength ratio (0.14; 95% CI: 0.01, 0.27). CONCLUSION: In this group of recreational female tennis players, significant differences in strength and strength ratio characteristics were identified. Although the design of the study precludes establishing a cause-and-effect relationship, the results suggest further study and treatment of the muscle groups of interest

Subacromial impingement syndrome and lateral epicondylalgia in tennis players

The purpose of this paper is to review the literature pertaining to subacromial impingement syndrome and lateral epicondylalgia (LE) in tennis players. The mechanisms of joint and muscular imbalances that lead to functional impingement of the shoulder joint may impair the stabilization and power function of the shoulder resulting in overcompensation of the wrist extensors during the tennis swing. This may contribute to microtrauma at the soft tissue structures at the lateral epicondyle thus causing symptoms of LE. Recent interest in the regional interdependence model as well as case studies published in the literature suggests that the relationship of proximal or distal joints should not be overlooked. Compensatory strategies at the distal upper extremity due to changes at the shoulder may overload smaller muscles in the forearm which cannot safely handle the extra stress, especially under repetitive conditions. Conditions of the shoulder and elbow that were previously considered to be independent, specifically subacromial impingement syndrome and lateral epicondylalgia, need to be critically reexamined in the context of regional interdependence given the potential association between the conditions. Specific studies examining the muscle and joint characteristics of the shoulder and elbow are needed as they relate to subacromial impingement syndrome and LE. Anatomic adaptations and biomechanical alterations in the upper extremity could result in abnormal stress loads and microtrauma at the shoulder and lateral elbow