Tennis Elbow / Lateral Epicondylitis
The outside of your forearm hurts and you do a quick Google search. You discover that the most likely cause of your pain is called Tennis Elbow. How could this be? You haven’t played tennis in years!
Tennis elbow, or lateral epicondylitis, is the most common problem of the forearm/elbow. While it is treatable, not all tennis elbows are the same, and they have to be assessed and treated differently in order to ensure success. In this article I will outline some of the typical factors that lead to tennis elbow and how to ensure you have an appropriate treatment plan.
Overuse Syndromes of the Elbow
Sixteen muscles cross the elbow joint. Nine of those muscles help to control our wrist and hand, and are used almost constantly throughout the day. These muscles also tend to get tight, be under-strengthened, and over-used. It’s a wonder why more of us don't develop forearm pain!
The second most common reason for elbow pain is golfer's elbow (medial epicondylitis), which affects the inside of the elbow. here are many other tendon problems that can occur near the elbow: Some of the more common ones include an inflamed tendon of the biceps, brachialis, brachioradialis or the triceps muscles. Before going any further, check out this article on tendon dysfunction to learn more about how tendons work and why they become injured: www.jacobcarterphysiotherapy.com/articles/tendon-function-and-dysfunction
Tennis elbow can present as pain/discomfort/stiffness on the outside of the elbow at rest or when gripping objects, moving the wrist or fingers, rotating the forearm, or bending/straightening your elbow. Often there will be pain when palpating/touching near the lateral epicondyle.
With chronic or very painful cases of tennis elbow, tears of the common extensor tendon may occur. This location is where most of the tendons that help to extend the wrist and fingers meet.
Acute tennis elbow can often be solved in a matter of weeks, however pain that persists (often because of inadequate treatment of the condition) may take 6-24 months to fully resolve. The most important step required to initiate healing is to develop a plan that addresses all of the contributing factors.
Factors that Contribute to Tennis Elbow
Here are a few common factors that contribute Tennis Elbow, and possible treatment options:
1. Repetitive Movement and Excessive Load
When tendons are required to withstand more volume or load than their structural integrity permits, the tendon will develop microscopic tears. The result is inflammation (which is actually important in the first stage of healing) and pain (due to the inflammation that activates local pain receptors). If you could simply allow the body to rest for 2-3 days, then start with some strengthening exercises, it is likely that your rehab would be much shorter.
Most individuals that develop tennis elbow spend a large amount of time doing a single task such as repetitive administrative work (e.g. typing on a computer), repetitive manual labour (e.g. using a hammer or screwdriver), mountain biking, rock climbing, etc. The key step here is to ensure variety in physical tasks so that there is an equal growth of the supporting forearm musculature.
We know that tendons respond best to slow increases in volume or load. An example of this would be a runner with ambitions of running a marathon: They will require at least a few months of slow progression in their training program to build strength of the connective tissue.
2. Forearm Muscular Imbalance
Functionally, the forearm extensor group is most often engaged to keep the wrist in a neutral position as you use the forearm flexor group to grasp and manipulate various items with your hand/fingers. Without the forearm extensors, the wrist would simply flex forward as seen here:
Therefore, if any of the other muscles that cause wrist or forearm movement (most significantly the wrist flexors) are tight, it often requires the wrist extensors to work excessively. If this increased load on the extensor tendon lasts long enough, tendinitis can occur.
As mentioned earlier, the muscles that extend the wrist and fingers attach to the elbow via the common extensor tendon. There is always a fine balance of muscle strength to flexibility required for optimal function. If muscles are weak, excess strain is placed upon the tendon to absorb the forces applied during movement. If muscles are tight, there is a resulting increased strain placed on the tendons at baseline, as the muscles constantly pull on the tendon.
3. Shoulder Tightness
As we expand our view to include the concept of regional interdependence, we must consider the shoulder, neck, and perhaps a focus on the thoracic spine, lumbar spine and pelvis. I would say that in my experience, it is possible to return an individual to their normal activities and sports by addressing the forearm alone in approximately 30% of cases. The other 70% of cases require an expanded view of the body. My reasoning for the success of addressing other areas of the body, in addition to the forearm, is as follows:
1. If we lack flexibility or strength at one joint, the neighbouring muscles and joints tend to make up for it.
2. If we have increased muscle tension in certain muscles, they may cause compression on the nerves that travel underneath of them and innervate the forearm muscles (e.g. the infraspinatus may compress the radial nerve at the shoulder, causing changes to the forearm muscles that are innervated by this nerve).
3. Compression of nerves at the neck, typically the lower cervical spine, can cause weakness to the muscles of the forearm and therefore be the cause of the forearm dysfunction… OR the nerve compression can refer pain to the elbow that mimics tennis elbow, causes pain when palpating the elbow and causes reduced strength to the muscles of the forearm.
4. Body Movement and Posture
The body develops pain for a reason. Often that reason has, at least part, to do with how you move - There is probably a movement pattern to blame.
To ensure full recovery, it’s important to use strategies and control-based exercises to address the poor movement patterns directly. This requires a skilled eye, knowledge of the sport, and ideally your Physiotherapist should watch how you move in your sport or at work. It is usually time consuming (and therefore, expensive) to have a Physiotherapist watch their clients perform their sport in person or go to their job site, but some video footage or photos can certainly help!
A few strategies to improve work-related causes of tennis elbow may include adjusting (A) Computer seat height, (B) Keyboard position, (C) Size of grip on various tools required at work, (D) Amount of vibration you are required to control with tools at work, (E) Number of rest breaks.
The initial stages of treatment for nearly any tendinopathy requires reducing muscle tension (via manual therapy and intramuscular stimulation (IMS)), addressing compensation patterns within the body, reducing the strain on the tendon by altering body mechanics, decreasing workload (rest), and possibly using braces/strapping.
If the tennis elbow is acute (having started within the last 3-6 weeks), then focus should be placed on rest and ice for a few days to reduce the level of pain to a 3/10. If needed, you may consider taking analgesics (e.g. acetaminophen), however you may want to restrict the use of anti-inflammatory medications (e.g. ibuprofen) as recent evidence suggests that restricting the initial inflammatory process may impair healing. As the acute level of pain settles, it is now time to start with strength and flexibility exercises that are tailored to your unique presentation, and gradual re-introduction of the activity that initially caused pain.
If the dysfunction is chronic (over 6 weeks worth of pain), the focus should be placed on increasing blood flow to the area, increasing the load tolerance of the affected tendons (via certain types of exercises) and Extracorporeal Shockwave Therapy (ESWT). Shockwave therapy has proven very effective in cases of thickened tendons (due to collagen/scar tissue accumulation) and calcification build up. These treatment techniques are used at specific intervals of time, and allow the body to resume its natural healing process.
In cases of tennis elbow that prove resistant to conservative treatment options, it may be helpful to consider other options: To rule out underlying pathology your Physiotherapist or Physician may refer you for diagnostic imaging, which may include an x-ray, ultrasound or MRI. Based off of these findings, a Sports Medicine Physician may consider an injection to reduce inflammation or encourage healing. The most popular injection options include corticosteroid (cortisone), prolotherapy, or platelet-rich protein (PRP).
No two cases of tennis elbow are exactly alike. It is important to understand the contributing factors that led to the dysfunction, and understand which stage of healing the injury is in. In more complicated cases that fail initial Physiotherapy management, diagnostic imaging may be warranted. Once all of this information is gathered, a skilled Physiotherapist or Sports Medicine Physician can then create a comprehensive plan that will maximize your success.
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Jacob Carter lives and works in Canmore, Alberta. He combines research evidence with clinical expertise to educate other healthcare professionals, athletes, and the general public on a variety of health topics.