At 12 weeks’ follow-up, however, patients in the active treatment group had significantly better long-term results than did controls (about 60% vs 40% improvement from baseline, respectively), especially in functional outcome measures. As the study authors noted, low-energy laser therapy carries a low risk for adverse effects, making it a long-term treatment strategy to be considered for patients with intractable lateral epicondylitis.20
Surgery
When conservative strategies implemented for several months do not resolve symptoms of lateral epicondylitis, surgical intervention may be required.2,21 Whether in open, percutaneous, or arthroscopic procedures, tendinopathic tissue is excised at the origin of the extensor carpi radialis brevis tendon in an effort to re-approximate the healthy tendon.21
Another less frequently used surgical procedure for lateral epicondylitis is extensor tendon release. In one long-term study investigating outpatient open extensor tendon release in 77 affected patients, researchers noted predominately good to excellent outcomes (ie, symptom relief, functional improvement), coupled with a low perioperative complication rate.29
PREVENTION
Prevention strategies are designed to mitigate the risk factors and minimize behaviors associated with each CTD. The science of ergonomics has produced numerous strategies intended to reduce the incidence of CTD through proper body mechanics, work habits, and equipment. In the workplace, CTD-specific ergonomic guidelines include posture training, reduction of excessive force and unnecessary repetition, and provision of adequate rest intervals. In addition to improving symptoms and possibly resolving some cases of lateral epicondylitis, ergonomic interventions may even reduce the incidence of new CTD in similarly exposed, asymptomatic workers30 (see “Proven Ergonomic Interventions”31,32).
Regarding specific prevention guidelines for lateral epicondylitis, several ergonomic recommendations can be offered to the patient and the patient’s employer. Consultation with a physical therapist may be helpful in developing specific recommendations focused on prevention of workplace injuries. Regarding CTD, physical therapists may recommend several tendon protection techniques that the clinician can then provide to the patient and his/her employer.33,34
Tendon protection techniques encourage proper body mechanics, avoidance of excessive force and repetition, as well as proper tool selection. Patients should be advised to avoid tasks that require unnecessary repetitive wrist flexion and extension, forearm pronation and supination, and strong, forceful gripping of objects. They should also avoid lifting objects with forearms pronated and wrists extended, as this will place increased tension and stress on the extensor tendon. Rather, patients should be advised to lift objects with their forearm supinated in a scooping motion (see Table 233).
Force is considered a significant contributor to the development of lateral epicondylitis. Thus, patients should be instructed to minimize forceful gestures at work, particularly with the forearm in full extension.34 Patients and employers should be advised to encourage use of proper tools for the tasks performed. Use of hand tools with lighter handles and larger grips requires less force than do tools with heavier, smaller grips, and are more likely to protect the upper-extremity tendons.
Finally, the worker who is required to perform a repetitive task for a sustained amount of time (eg, certain tasks performed by an electrical contractor; steady use of a computer workstation) is likely to benefit from small “micro-breaks” of a few minutes each hour. This habit may reduce cumulative stress, and possibly the incidence of CTD, including lateral epicondylitis.32,34
CONCLUSION
Primary care and occupational medicine clinicians, as well as providers in other frontline specialties, have a great deal to offer in regard to stemming the disabling symptoms and fiscal strain associated with lateral epicondylitis. While early recognition and intervention for patients with symptoms of lateral epicondylitis are essential to the clinician’s role, providers must also focus on key preventive measures. Involving key stakeholders, including patients and their employers and managers, in establishing appropriate safety measures in the workplace is an optimal strategy. The formation of a multidisciplinary health care team that includes ergonomists, physical therapists, and orthopedic specialists may also prove beneficial in both treatment and prevention.
REFERENCES
1. Noteboom T, Cruver R, Keller J, et al. Tennis elbow: a review. J Orthop Sports Phys Ther. 1994;19(6):357-366.
2. Cohen MS, Romeo AA. Lateral epicondylitis: open and arthroscopic treatment. J Am Soc Surg Hand. 2001;1(3):172-176.
3. Rabago D, Best TM, Zgierska AE, et al. A systematic review of four injection therapies for lateral epicondylosis: prolotherapy, polidocanol, whole blood and platelet-rich plasma. Br J Sports Med. 2009;43(7):471-481.
4. Calfee RP, Patel A, DaSilva MF, Akelman E. Management of lateral epicondylitis: current concepts. J Am Acad Orthop Surg. 2008;16(1):19-29.
5. Titchener AG, Fakis A, Tambe AA, et al. Risk factors in lateral epicondylitis (tennis elbow): a case-control study. J Hand Surg Eur Vol. 2012 Apr 4. [Epub ahead of print]