What treatment options are available for tennis elbow that has progressed to upper arm pain?

Treatment Options for Tennis Elbow Progressing to Upper Arm Pain

Comprehensive treatment for tennis elbow that has progressed to upper arm pain should include a combination of conservative management, physical therapy, and possibly second-line interventions, with surgery reserved for refractory cases.

First-Line Conservative Management

• Relative rest and activity modification are essential to prevent ongoing damage while promoting tendon healing, though complete immobilization should be avoided to prevent muscular atrophy 1
• Modify or temporarily stop activities that aggravate symptoms while continuing those that don't worsen pain 1
• Apply ice (cryotherapy) for 10-minute periods through a wet towel to provide effective short-term pain relief 1
• Use NSAIDs (oral or topical) for pain relief, though they may not affect long-term outcomes 1
• Consider counterforce bracing/orthotics (tennis elbow bands) to help reinforce, unload, and protect tendons during activity 2, 1

Physical Therapy Interventions

• Eccentric strengthening exercises are superior to concentric exercises for promoting tendon healing, increasing strength, and reducing pain 1, 3
  • Eccentric exercise showed 10% higher response rates at all levels of pain reduction compared to concentric exercise 3
• Include stretching exercises for the wrist extensors to improve range of motion and function 1, 4
• Deep transverse friction massage can effectively reduce pain 1
• Consider shoulder stabilization exercises, as they have shown significant improvement in grip strength and pain thresholds in the upper trapezius muscle 5
  • This is particularly important when tennis elbow has progressed to upper arm pain, suggesting involvement of proximal structures

Second-Line Treatments

• Corticosteroid injections may provide short-term relief but should be used with caution 2, 1
  • They may inhibit healing and reduce tendon tensile strength, potentially predisposing to spontaneous rupture 2
  • Studies show significant short-term benefits of corticosteroid injections are paradoxically reversed after six weeks, with high recurrence rates 6
• Therapeutic ultrasound may decrease pain and increase collagen synthesis, though evidence for consistent benefit is weak 2
• Extracorporeal shock wave therapy (ESWT) appears safe and effective but requires further research 2, 1

Treatment Algorithm

1. Initial phase (0-4 weeks): Rest, activity modification, ice application, NSAIDs, and bracing 1
2. Rehabilitation phase (2-8 weeks): Progressive eccentric strengthening exercises, stretching, and continued bracing as needed 1
   • Include shoulder stabilization exercises when pain has progressed to the upper arm 5
3. For persistent symptoms: Consider corticosteroid injection or other second-line modalities 1
4. For refractory cases (>6-12 months): Surgical consultation 1
   • Surgery typically includes excision of abnormal tendon tissue and longitudinal tenotomies to release areas of scarring and fibrosis 2

Diagnostic Considerations

• Plain radiographs of the elbow are appropriate initial imaging to rule out other causes of elbow pain 7
• MRI may be considered if radiographs are normal or nonspecific and there is suspicion of tendon degeneration or tear 7

Common Pitfalls and Caveats

• Overreliance on corticosteroid injections may lead to tendon weakening and potential rupture 2, 1
• Complete immobilization should be avoided as it leads to muscle atrophy and deconditioning 1
• Physiotherapy combining elbow manipulation and exercise has superior benefits to wait-and-see approaches in the first six weeks and to corticosteroid injections after six weeks 6
• Failure to address shoulder and upper arm involvement may lead to incomplete recovery when tennis elbow has progressed to upper arm pain 5