Elbow and Forearm Tendinopathy

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Elbow and Forearm Tendinopathy Evidence Based
Medicine Literature Review and Protocol Peggy
C. Haase, OTR, CHT
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Level IV Advancing Project Peggy C. Haase, OTR,
CHT

• Completed evidence based medicine review of
  current therapy choices for upper extremity
  tendinopathy, focusing on the elbow and forearm,
  including proximal forearm muscle belly as well
  as insertional lateral tendinopathy, insertional
  medial tendinopathy, and insertional triceps
  tendinopathy
• Articles reviewed and placed in research summary
  grid
• Developed conservative management treatment
  protocol for elbow and forearm tendinopathy,
  including forearm muscle belly and elbow
  insertional tendinopathy
• Developed patient education handouts for active,
  resistive, eccentric, and eccentric resistive
  exercises
• Presented findings to Hand UE Focus Group at
  the June 22, 2009 meeting

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Evidence Based Literature Review

• Reviewed 18 articles on tendinopathy,
  evidence-based practice for hand therapists,
  wrist hand overuse, elbow forearm
  tendinopathy
• 9 Level 1 evidence articles
• 2 Level 2 evidence articles
• 2 Level 3 evidence articles
• 5 Level 5 evidence articles

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Literature Review Reveals Support for Use

• Level 1 and Level 2 Evidence for
• Ultrasound
• Phonophoresis
• Electrical Stimulation
• Iontophoresis
• Manual Therapy
• Stretching
• Concentric Exercises
• Eccentric Exercises
• Strengthening Exercises
• Counterforce Brace
• Consider 6 weeks of home therapy

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Literature Review Reveals Weak or No Evidence
for Use

• Low-Intensity Laser
• Transverse Friction Massage

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Progressing to Return to Normal Activity Level

• Level 3 and Level 5 Evidence for
  use of
• Rest
• Supportive devices as splint, brace
• Assessment of total mechanics of body, not just
  the local area presenting with the discomfort
• Activity assessment for activity modification
• Progressive reconditioning program for strength,
  flexibility, endurance, and eccentric exercises

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Nirschl Pain Phase Scale

• Phase 1. Stiffness or mild soreness after
  activity. Pain is usually gone within 24 hours.
• Phase 2. Stiffness or mild soreness before
  activity that is relieved by warm-up. Symptoms
  are not present during activity, but return
  afterward, lasting up to 48 hours.
• Phase 3. Stiffness or mild soreness before
  specific sport or occupational activity. Pain is
  partially relieved by warm-up. It is minimally
  present during activity, but does not cause the
  person to alter activity.
• Phase 4. Similar to phase 3 pain but more
  intense, causing the person to alter performance
  of the activity. Mild pain occurs with activities
  of daily living, but does not cause a major
  change in them.
• Phase 5. Significant (moderate or greater) pain
  before, during, and after activity, causing
  alteration of activity. Pain occurs with
  activities of daily living, but does not cause a
  major change in them.
• Phase 6. Phase 5 pain that persists even with
  complete rest. Pain disrupts simple activities of
  daily living and prohibits doing household
  chores.
• Phase 7. Phase 6 pain that also disrupts sleep
  consistently. Pain is aching in nature and
  intensifies with activity.

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Elbow and Forearm Tendinopathy Conservative
Treatment Guide March 2009

• Phase 1 - Acute Phase (1-3 weeks)
• Rest, use of cool, may use
  splint for pain management, PAMs include 20
  pulsed ultrasound, ultrasound-electrical
  stimulation combo, iontophoresis with
  dexamethasone
• Rehabilitation Phase
  (2 weeks 12 months)
• Phase II - Early Rehab Phase most patients
  enter treatment now
• Activity (ADL, sport, work)
  assessment for possible aggravating activities
  with suggestions for activity adjustments to
  decrease pain and increase function
• May add use of counterforce brace
• Warming up/cooling down with
  activity and exercises
• Active motion exercises for elbow,
  forearm, wrist
• Active eccentric exercises for
  affected muscle
• May add passive stretches
• PAMs include 50 pulsed
  ultrasound, phonophoresis with dexamethasone gel,
  iontophoresis with dexamethasone
• May progress to overall
  conditioning program as VOI Fitness Center
• Phase III - Late Rehab Phase
• Continue with warming up/cooling
  down with activity and exercises
• Continue with active exercises
  and active eccentric exercises
• Add conditioning/strengthening
  exercises eccentric to concentric exercises
• Pain is guide to decrease repetitions, decrease
  weight, decrease speed, decrease time with
  activity seen Nirschl Pain Phase Scale - as
  pain is decreased, then may increase program
• Progress to concentric
  resistive exercises when no pain with two
  consecutive sessions with active and active
  eccentric exerciss
• Progress to return to activity
  as pain remains decreased

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Resources

• Journal of Hand Therapy
• American Journal of Sports Medicine
• British Journal of Sports Medicine
• Clinic Orthopaedics Related Research
• Rheumatology Journal
• Clinics in Sports Medicine
• Modalities for Therapeutic Intervention, 4th
  Edition
• Evidence-Based Guide to Therapeutic Physical
  Agents
• Arm Care, Robert Nirschl

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Thank You