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Iontophoresis Protocol:

Tennis Elbow
Lateral Humeral Epicondylitis
1
ETIOLOGY PATIENT EVALUATION

Lateral humeral epicondylitis most often affects the A. Subjective:


extensor carpi radialis brevis tendon or the tenorpriosteal Patient complaint
junction, as this muscle is most active in pure wrist Location
extension. Inflammation results from: 1) incorrect Onset and duration of symptoms
wrist motion, 2) overuse, 3) age-related tissue Description of symptoms (i.e. numbness, pain
[constant, dull, sharp] hypersensitivity, stiffness);
changes, making the tendon less flexible and more
use pain scale
prone to injury, or 4) direct trauma.
Pattern of when symptoms occur (AM, PM, after
activity, etc.)
Pain is felt over the lateral epicondyle, often with Self-help or other formal treatment
referred pain from muscle trigger points to the dor- Other medical problems
sum of the hand and wrist. This muscle-tendon Concurrent medications and allergies
junction is tested by: 1) resisting wrist extension
with an extended, pronated elbow, or 2) passively B. Objective (also compare with uninvolved elbow):
flexing an ulnar deviated fist while the elbow is in
an extended, pronated position. 1. Inspection
Carrying angle, arm posturing
Redness, swelling, warmth
Scars
Inflammed
Extensor 2. Palpation:
Tendon Bone: lateral epicondyle, radial head, medial
epicondyle, olecranon, olecranon fossa
Soft tissue: muscles and tendons (laterally,
anteriorly, medially, posteriorly)
Typical Drug
Electrode Site 3. Mobility:
Active and passive ROM (flexion, extension,
supination, pronation)
Forearm 4. Muscle Testing:
Extensor Wrist: extensors, flexors, supinators,
Muscles pronators
Elbow: extensors and flexors

Typical 5. Provocation Tests:


Dispersive Tennis Elbow Test: Have patient make a fist
and extend wrist; stabilize the pronated elbow
Pad Site (or
and resist wrist extension. Sudden severe pain
on biceps)
at the lateral epicondyle is a positive sign. Also
use a passive test: with patient's elbow extend-
ed and pronated, passively flex and ulnar devi-
ate the wrist, while maintaining elbow exten-
sion. Lateral epicondyle pain is a positive sign.
(Objective continued) IONTOPHORESIS PROCEDURE

6. Neurological: IMPORTANT: See iontophesis system and electrode instruc-


Reflexes, sensation tion guides for indications, contraindications, warnings, precau-
tions and directions for use.
7. Other Joints:
1. Clean skin is absolutely necessary to minimize or elim-
Test neck, shoulder, wrist and hand for
inate skin irritation. Clean both electrode sites vigor-
secondary involvement ously with an alcohol wipe prior to applying electrodes
to remove dry skin, salts and oils. Excess hair may be
8. Review x-ray films and physician's report trimmed with scissors or electric clippers. Do not
shave skin. Doing so may result in excessive irritation
C. Assessment: or burns.
1. Problem list
2. Goals 2. Prepare electrodes according to package instructions.
3. Recommended Treatment:
Iontophoresis ( medications, dosages, elec- 3. Place the drug electrode over the involved lateral epi-
trode size) condyle at its most tender point.
Other modalities (e.g. ice or heat, tennis
4. The dispersive pad may be placed proximal or distal to
elbow strap, stretching, strengthening, home the drug electrode, over a major muscle (e.g. biceps,
program, activity or sport re-education for triceps, or on the forearm). Never tape, bind or com-
prevention of re-injury, etc.) press either electrode in any way. Properly prepared
Oral or injectable medications (administered drug electrodes and dispersive pads do not require
by physician, e.g. NSAIDs, corticosteroids) added fixation on properly prepared skin.

D. Plan: 5. Do not allow the patient to extend or flex the arm or to


1. Frequency and duration of treatment press on or lean against the electrodes during treat-
2 Date(s) for assessment of progress ment. This prevents circuit breaks and minimizes the
possibility of excessive skin irritation or burns.
WHY IONTOPHORESIS IS
6. Treat for 40 milliampere-minutes according to the
APPROPRIATE THERAPY package instructions.
Iontophoretic drug delivery for the condition of lateral 7. Treat every other day. Usually, no more than six treat-
epcondylitis provides an alternative to hypodermic injec- ments are required, but there is no contraindication for
tion of corticosteroids, with increased comfort and additional treatments.
decreased systemic side effects. It allows short term
administration and avoids the associated discomfort of REFERENCES
needle insertion at an already tender area of tissue.
1. Hartley, A. 1990. Practical Joint Assessment. Mosby Year
Avoiding the use of a hypodermic needle also prevents
Book. St. Louis.
further tissue trauma and eliminates the risk of infection at
the injection site. Also, the risk of potential necrosis 2. Hoppenfeld, S. 1976. Physical Examination of the Spine
and/or tendon weakening associated with bolus injections and Extremities. Appleton-Century-Crofts. New York.
of corticosteroids is eliminated. Tennis elbow is usually a
very well localized condition, appropriate for electrode 3. Saunders, H.D. 1985. Evaluation, Treatment and Prevention
placement over the affected site. of Musculoskeletal Disorders. W.B. Saunders. Minneapolis.

RE-EVALUATION 4. Warwick, R. and Williams, P. 1983. Gray's Anatomy, 35th


British Ed. W.B. Saunders. Philadelphia.
In addition to patient's subjective reports, check for:
Distributed By:
decreased pain, decreased tenderness to palpation at the Edited By: For:
Rebecca Stephenson, PT IOMED, Inc. Balego & Associates, Inc.
lateral epicondyle and extensor carpi radialis brevis mus-
Stephenson Physical Therapy 2441 South 3850 West, Suite A 1-800-322-2781,
cle, decreased swelling, negative tennis elbow sign or locally 651-633-7102
increased strength and endurance of the forearm extensors 335 Main Street Salt Lake City, Utah 84120 USA
Fax: 651-633-0024
and resolution of radiating pain. Medfield, MA 02052 Ph. 800.621.3347 Fax 800.318.7793 www.BalegoOnline.com

IOMED, Inc., 1993. Printed in USA. 3/03. All rights reserved.