As clinicians, we have many challenging conditions that we care for, but lateral epicondylitis has to rank up there near the top. There are many treatment approaches that have been used and reported, which show that while we get good results, they are short lived.
Current evidence is extremely valuable to help us move forward, and improve outcomes, as we care for people with this difficult diagnosis. There are several factors that will help us improve our care of lateral epicondylitis. This starts with a change in philosophy on how we view lateral epicondylitis. This philosophical change produces a change in how we evaluate and treat it.
Evidence tells us that the pathology in the common extensor origin is angiofibroblastic tendinosis. With this pathology, micro tears attempt to heal themselves, but before they can completely heal, more micro tearing occurs. This vicious cycle repeats itself over and over again.
Evidence also suggests that this is a problem caused by overuse. Overuse activities that tend to be associated with lateral epicondylitis are forceful or repetitious tasks that require supination &/or wrist extension.
One key philosophical question that we must ask ourselves before we can fully incorporate this evidence into practice is, “which body part(s) are being “underused?” In other words, are there other areas, proximal or remote to the lateral elbow that are dysfunctional, and putting the common extensor origin in a situation where it has to perform above its capacity, causing injury? When we think about lateral epicondylitis this way, our philosophy changes on why it may be occurring. When this change of thought occurs, it allows us to consider other areas to evaluate and treat for this difficult condition by understanding how our body parts are linked together and how they impact one another.
We can enhance our evaluation methods by testing other areas of the body, both proximal and remote. At the shoulder level for example, shortness or stiffness of the pectoralis minor, as a scapular downward rotator, can impede normal upward rotation when flexing the arm for reach-grasp activities. This causes a dysfunctional chain of events to occur. Since the scapula cannot upwardly rotate properly, the next kinetic link, being the glenohumeral joint, recruits more muscles to flex the arm. This results in poor positioning of the arm, which then causes additional adjustments to be made at the forearm level and down the line.
Even though it is easy to overlook, remote body parts like the trunk and legs play a bigger part than what we give them credit for in successfully completing upper extremity demands. Screening them for motion and strength is another component of evaluation that we can utilize to ensure that we thoroughly understand the whole clinical picture.
Optimizing our treatment approaches includes incorporating other body parts into our treatment plans and methods. If we identify proximal &/or remote areas that are dysfunctional, we can then implement treatment that addresses the dysfunction. Choosing treatment methods that impact posture, and progress the patient toward normalization of their movement patterns is exactly what is needed. The goal of this treatment approach is to improve performance of the dysfunctional body segments so that the injured area (the common extensor origin) can heal, avoid the continued cycle of re-injury, and allow the person to return to the activities that are important to them.
This kinetic chain approach to lateral epicondylitis is very exciting because it does seem to be effective in making positive changes in patients who have this condition. It appears to be a piece of the puzzle that we are missing, which will lead us to better and longer lasting positive outcomes for this challenging condition.