Tendinopathies of the forearm and wrist

Tendinopathies are common in the upper limb; despite lower force generation, there are more sustained levels of activity and higher repetition tasks than in the lower limb. Muscle-tendon units in the leg are subject to higher forces, often against total body weight, generating high-velocity movements. Translating research findings from the lower limb to the arm is not straightforward however, there are similarities in tendinopathies occurring where there is an element of compression, such as over the radial head in elbow extension and pronation. Wrist and finger tendinopathies also occur under retinacular structures at the wrist and the pulleys of the fingers.

The Hand Therapy NZ conference in March 2022 showcased Dr. Jill Cook as the keynote speaker who outlined rehabilitation strategies for managing tendinopathy. Jill described the conservative treatment as focussing on the doughnut – the healthy tendon tissues that remain and surround the areas of tendinopathy – the ‘hole’. A graphic slide showed the underside of the common extensor tendon revealing grey, gelatinous tissue in the deeper fibres of the ECRB tendon overlying the radial head.

Mainstays of treatment for tennis elbow include maintaining load across the involved muscle-tendon unit to preserve strength and integrity of uninvolved tendon tissue and in managing the disability and distress surrounding these problems:

• Avoiding the use of rest as this is rarely helpful, often resulting in deconditioning and establishing relative disability with the distress related to this.
  
• Education and support in self-management include setting realistic timeframes and duration of therapy. Rehabilitation can often include three months of exercise, with the natural history of the condition being an improvement in symptoms over a period of over one year.
• Exercising and loading the involved tendon in a pain free way – isometric exercises including sustained contractions for at least 45 seconds at a time, 4-5 reps, and gradually bringing these muscles into pain-free functional tasks and sport as soon as possible.
• Evidence supports the use of manual therapy techniques (we often target the superior radioulnar joint with mobilisations with movement) along with therapeutic exercise for improved outcomes at one year in tennis elbow patients.
• Review of unhelpful painful movement patterns in the upper limb, leading to the development of a strengthening programme for underused muscle groups. We often find that tennis elbow patients have dominant radial wrist movement patterns when lifting and gripping, with associated rotator cuff issues and tight upper fibres of trapezius in tandem with their sore lateral elbow.
• Careful use of language surrounding radiology imaging - avoiding castrophization when reviewing ultrasound scans reporting tears etc.
• Realistic advice about the efficacy of PRP injections and shockwave therapy as there is a lack of evidence that they secure better outcomes. Indeed, evidence suggests that cortisone injection for this condition is not helpful in the long term.
• Patients with unrelenting symptoms that extend beyond expected timeframes or with debilitating pain and those who have evidence of acute tendon calcification or concurrent radial nerve compression are referred for Specialist review.