Postoperative Rehabilitation Protocol Repair of Common Extensor Tendon

Adam Barnard, PA-C

acbarn215@gmail.com

Owensboro Health Orthopedics

And Sports Medicine

270-417-7940

 

 

The purpose of this protocol is to assist the Physical Therapist with guidance on the post-operative rehabilitation course of a patient who has undergone Common Extensor Tendon repair for lateral epicondylitis.  It is by no means intended to replace or substitute the clinical decision-making process of the therapist assisting the post-operative patient in their recovery.  A patient’s individual needs are based on many factors including physical exam findings, rate of progression, presence of post-operative complications, personal goals/aspirations/expectations, and potentially confounding medical diagnoses/conditions. If the therapist/clinician has concerns, recommends urgent evaluation, or patient specific alterations to the protocol, they should contact myself(acbarn215@gmail.com) or our office staff directly(270-417-7940).  

 

Phase I- Early Post-Operative Phase (Post-op Day 0-7)

The goal of physical therapy intervention during the early post-operative phase is to protect the repair, reduce swelling and edema, and monitor wound healing. 

Goals: 

  1. Implement use of nonpharmacologic modalities to control pain and swelling such as icing, manual massage, elevation of the extremity, etc
  2. PROM of elbow 45-120

Assessment by Therapist:

  1. Shoulder ROM and scapular mechanics
  2. Assess for signs of wound infections, DVT/PE, Nerve palsy/dysfunction 

 Therapeutic Exercises:

  1. Gentle hand, wrist, elbow, shoulder RROM if pain controlled.  Also OK to begin AAROM/AROM shoulder immediately post-op

Precautions:

  1. Wrist splint on unless bathing or PT  
  2. Sling for comfort unless bathing or PT 

Phase II (Post-op Week 1-6)

Goals:

  1. Full PROM by end of phase II, may progress as tolerated 
  2. Decrease swelling/inflammation (Ice, TENS unit, Dry Needling, Cupping, etc)
  3. Week 2: 45 degrees to full flexion. 
  4. Week 3: 30 degrees to full flexion. 
  5. Week 4: 20 degrees to full flexion. 
  6. Week 5: 10 degrees to full flexion.  
  7. Week 6: 0 degrees to full flexion

Assessment by Therapist:

  1. Assess frequency of narcotic and non-narcotic analgesic use 
  2. Assess pre-treatment and post-treatment ROM 
  3. Encourage avoidance of nicotine/smoking and control of glucose if diabetic 


Therapeutic Exercises:

  1. Begin submaximal isometrics hand, wrist(flexion only), elbow, shoulder
  2. AROM of shoulder as tolerated
  3. May begin shoulder isotonics week 3 if acceptable ROM and not painful 
  4. May begin unresisted/unweighted AROM of elbow after first follow-up appointment at two weeks post-op

Precautions:

  1. Wrist brace should be used unless patient is bathing, resting with elbow/forearm/wrist supported and avoiding use (ie arm resting on couch/recliner/pillows), or under direct supervision by physical therapist.  Sling may be discontinued after 2 weeks 
  2. No resisted wrist extension exercises until after 6 weeks 

 

Phase III (Post-op Week 6-12)

Goals:

  1. Initiation of elbow eccentrics after 2nd post-op visit @ 6 weeks 
  2. Maintain full AROM of hand/wrist/elbow/shoulder
  3. Discontinue wrist brace 

Therapeutic Exercises:

  1. Begin gradual weighted and band resistance hand/wrist/elbow/shoulder
  2. Begin combined motions (extension with pronation/supination) if adequate pain control
  3. Advance scapulothroacic and rotator cuff exercises (pulley, wall walks/slides, forearm planks, shrugs/rows) as tolerated
  4. Initiate pushup progression (Wall pushups-->incline pushups--> horizontal pushups) 
  5. OK for running/cycling

Precautions:

  1. Do not increase weighted wrist extension if pain/swelling
  2. No throwing exercises
  3. No rapid movements (excessive/forceful muscle contractions) 

Phase IV (Post-op Week 12-16)

Goals:

  1.  Advance combined/composite strengthening movements and ensure proper mechanics of hand/wrist/elbow/shoulder
  2. Continue Phase I, II and III exercises
  3. Progressive strengthening and complete functional activities/heavier ADLs above and below shoulder height
    1. Progress endurance before strength (ie. higher reps before adding resistance)

Therapeutic Exercises:

  1. Initiate plyometric and sport specific exercises and titrate throwing if no pain 
  2. Bench Press
  3. Lat pull down
  4. Seated rows
  5. Overhead Press 

Precautions:

  1. Do not advance strengthening exercises if lacking full ROM or experiencing pain
  2. Do not progress shoulder strengthening exercises unless proper scapulothoracic mechanics
  3. Must have clearance before return to work or sport 

Phase V (Post-op Week 16+)

Goals:

  1. Increase strength as tolerated/required
  2. Work conditioning/hardening
  3. Release to work/sport without restrictions.  Obtain clearance if not obtained during phase IV

Therapeutic Exercises:

  1. No restrictions if pain free 
  2. Transition to home/gym program 

Precautions: 

Do not advance strengthening exercises if patient experiencing painful response.  Goal is maximize endurance of movements before increasing loads